Intimate Partner Violence PTSD and Neural Correlates of Inhibition

Posttraumatic stress disorder (PTSD) has been linked to deficits in response inhibition, and neuroimaging research suggests this may be due to differences in prefrontal cortex recruitment. The current study examined relationships between PTSD from intimate partner violence (IPV) and neural responses during inhibition. There were 10 women with PTSD from IPV and 12 female control subjects without trauma history who completed the stop signal task during functional magnetic resonance imaging. Linear mixed models were used to investigate group differences in activation (stop–nonstop and hard–easy trials). Those with PTSD exhibited greater differential activation to stop–nonstop trials in the right dorsolateral prefrontal cortex and the anterior insula and less differential activation in several default mode regions (d = 1.12–1.22). Subjects with PTSD exhibited less differential activation to hard–easy trials in the lateral frontal and the anterior insula regions (driven by less activation to hard trials) and several default mode regions (i.e., medial prefrontal cortex, posterior cingulate; driven by greater activation to easy trials; d = 1.23–1.76). PTSD was associated with difficulties disengaging default mode regions during cognitive tasks with relatively low cognitive demand, as well as difficulties modulating executive control and salience processing regions with increasing cognitive demand. Together, these results suggest that PTSD may relate to decreased neural flexibility during inhibition.     

Emotional Processing of Imaginal Exposures Predicts Symptom Improvement: Therapist Ratings Can Assess Trajectory in Prolonged Exposure for Posttraumatic Stress Disorder

Research on mechanisms of change in prolonged exposure therapy (PE), an evidence-based treatment for posttraumatic stress disorder (PTSD), is ongoing. Two putative mechanisms of change are engagement during imaginal exposure and trauma-related belief change. The PE Therapist Questionnaire (PETQ), a novel measure based on the emotional processing theory underlying PE, was developed as a practical tool for therapists to use to assess (a) patient engagement during imaginal exposures and (b) perspective shifts during postimaginal processing. Patients (N = 151) at a U.S. Veterans Affairs medical center PTSD specialty clinic completed self-report measures of PTSD and depression symptoms prior to sessions. Study therapists (n = 17) completed the PETQ postsession. Rational construction and psychometric analyses suggested a two-component solution for the PETQ: imaginal and processing. The imaginal factor did not relate to PTSD and depression symptoms. The processing factor correlated with current and next-session PTSD and depression symptoms, with medium effect sizes, rs = −.41 to −.45, ps < .001. Controlling for current-session PTSD and depression, a higher level of processing predicted lower next-session PTSD severity, with a small effect size, β = −.38, p < .04. Postexposure emotional processing, which supports positive changes in maladaptive trauma-related beliefs and tolerance of emotional distress, predicted future symptom improvement, highlighting the importance of processing components in PE. Further, the use of therapist observations may offer ancillary methods less influenced by correlation of within-patient subjective ratings and concomitant risk of construct overlap in mechanisms research.     

Comparing Exposure- and Coping Skills–Based Treatments on Trauma-Related Guilt in Veterans With Co-Occurring Alcohol Use and Posttraumatic Stress Disorders

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) commonly co-occur, and this comorbidity (PTSD–SUD) is associated with more severe symptoms and functional impairment than either disorder alone. Growing evidence indicates that trauma-related guilt, typically concerning negative appraisals of one's actions or inaction during a traumatic event, is associated with PTSD, depression, suicidality, and, possibly, substance use. The present study examined whether integrated treatment for PTSD–SUD was effective in reducing trauma-related guilt as measured by the Trauma-Related Guilt Inventory. Data were drawn from a randomized clinical trial comparing the effectiveness of two integrated therapies on treatment outcomes in a sample of U.S. veterans (N = 119) with comorbid PTSD and SUD. Participants were randomized to receive either Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE; n = 63) or Seeking Safety (SS; n = 56). The results indicated that global guilt decreased over time for the whole sample. However, there was a significant Treatment × Time interaction, such that participants in the COPE condition reported lower rates of global guilt, d = 0.940, over time compared to those in the SS condition, d = .498. To our knowledge, this was the first study to examine the effects of integrated PTSD–SUD treatment on trauma-related guilt. The findings highlight that exposure-based, trauma-focused treatment for comorbid PTSD–SUD can be more effective in decreasing trauma-related guilt, with potentially longer-lasting effects, than non–exposure-based treatment, adding evidence that patients with PTSD–SUD should be offered such treatment.     

Treatment of Adolescent PTSD: The Impact of Prolonged Exposure Versus Client‐Centered Therapy on Co‐Occurring Emotional and Behavioral Problems

The present study evaluated secondary emotional and behavioral outcomes among adolescents who received prolonged exposure (PE‐A) or client‐centered therapy (CCT) for posttraumatic stress disorder (PTSD) in a randomized controlled trial. Participants were 61 adolescent girls (age: M = 15.33, SD = 1.50 years) with sexual abuse related PTSD seeking treatment at a community mental health clinic. Multilevel modeling was employed to evaluate group differences on the Youth Self‐Report (YSR) over acute treatment and 12‐month follow‐up. Both treatment groups showed significant improvements on all YSR scales from baseline to 12‐month follow‐up. Adolescents who received PE‐A showed significantly greater reductions than those receiving CCT on the Externalizing subscale (d = 0.70), rule‐breaking behavior (d = 0.63), aggressive behavior (d = 0.62), and conduct problems (d = 0.78). No treatment differences were found on the Internalizing subscale or among other YSR problem areas. Both PE‐A and CCT effectively reduced many co‐occurring problems among adolescents with PTSD. Although PE‐A focuses on PTSD and not on disruptive behaviors, PE‐A was associated with greater sustained changes in externalizing symptoms, supporting broad effects of trauma‐focused treatment on associated problem areas.     

Guilt in the Treatment of Posttraumatic Stress Disorder Among Active Duty Military Personnel

The current study examined the role of trauma‐related guilt on posttraumatic stress disorder (PTSD) symptom change during prolonged exposure therapy (PE) as well as the efficacy of PE in reducing three dimensions of guilt (responsibility, wrongdoing, and lack of justification) during treatment. Participants were 331 active duty U.S. military personnel seeking treatment for PTSD who were randomized to one of four groups: massed PE (10 sessions delivered over 2 weeks), spaced PE (10 sessions delivered over 8 weeks), present‐centered therapy (PCT; 10 sessions delivered over 8 weeks), or minimal contact control (MCC; weekly therapist phone check‐in for 4 weeks). The results showed that baseline guilt did not predict reductions in PTSD symptoms for spaced PE or for PCT, ps = .178–.387, ds = ?0.02–0.07. Treatment condition (massed PE vs. MCC; spaced PE vs. PCT) did not moderate reductions in guilt for spaced PE versus PCT. Guilt decreased significantly over treatment in all groups, p < .001 to p = .038, ds = ?0.19 to –0.42, except concerning justification in the spaced PE and PCT groups, p = .140, d = ?0.10. The findings suggest that guilt may be reduced significantly following active PTSD treatment and attention control and that PTSD recovery is not impacted by baseline levels of trauma‐related guilt in military personnel with PTSD, although reported levels of guilt were low to moderate in this sample.     

Identifying Change Targets for Posttraumatic Stress Disorder Among Suicidal and Self-Injuring Women With Borderline Personality Disorder

Research on psychotherapies for posttraumatic stress disorder (PTSD) is increasingly focused on understanding not only which treatments work but why and for whom they work. The present pilot study evaluated the temporal relations between five hypothesized change targets—posttraumatic cognitions, guilt, shame, general emotion dysregulation, and experiential avoidance—and PTSD severity among women with PTSD, borderline personality disorder, and recent suicidal and/or self-injurious behaviors. Participants (N = 26) were randomized to receive 1 year of dialectical behavior therapy (DBT) with or without the DBT prolonged exposure (DBT PE) protocol for PTSD. Potential change targets and PTSD were assessed at 4-month intervals during treatment and at 3-month posttreatment follow-up. Time-lagged mixed-effects models indicated that between-person differences in all change targets except guilt were associated with more severe PTSD, η²s = .32–.55, and, except for general emotion dysregulation, slowed the rate of change in PTSD severity over time, η²s = .20–.39. In DBT but not in DBT + DBT PE, individuals with higher levels of guilt and experiential avoidance relative to their own average had more severe PTSD at the next assessment point, η²s = .12–.25. The associations between the proposed change targets and PTSD severity were not bidirectional, except for general emotion dysregulation, η² = .50; and posttraumatic cognitions, η² = .06. These preliminary findings suggest that trauma-related cognitions, shame, and guilt, as well as problems regulating them, may be important change targets for improving PTSD in this patient population.     

The Moderating Effect of State Anger on Treatment Outcome in Female Adolescents With PTSD*

Trauma experienced in childhood and adolescence negatively affects the development of adaptive regulation of emotions and is associated with greater symptoms of anger. Prior research has suggested that high levels of anger may impede the outcome of treatment in adults with posttraumatic stress disorder (PTSD). The current study investigated whether high levels of anger resulted in poorer treatment outcomes in adolescent girls with PTSD. Participants included 61 female adolescent survivors of sexual abuse or assault who were randomized to either prolonged exposure for adolescents (PE‐A) or client‐centered therapy (CCT) for traumatized children for 8–14 weekly sessions. Participants were followed for 12 months posttreatment. High levels of state anger at baseline were associated with less improvement in PTSD symptoms in the CCT group than the PE‐A group (d = 0.62). The moderating effects of state anger on improvement in PTSD symptoms was significant with emotion regulation difficulties, which may underlie anger symptoms (d = 0.58) in the model. The results of this study suggessted that high state anger was less of an impediment to treatment of PTSD for those receiving PE‐A than those receiving less differentiated approaches such as CCT.     

The Neurocognitive Performance of Female Veterans With Posttraumatic Stress Disorder

Neurocognitive problems are common with posttraumatic stress disorder (PTSD) and are important to understand because of their association with the success of PTSD treatment and its potential neural correlates. To our knowledge, this is the first neurocognitive study in an all‐female U.S. veteran sample, some of whom had PTSD. We examined neurocognitive performance and assessed whether learning deficits, common in PTSD, were associated with executive functioning. Veterans with PTSD (n = 56) and without (n = 53) were evaluated for psychiatric and neurocognitive status. The PTSD group had a lower estimated IQ (d = 0.53) and performed more poorly on all neurocognitive domains (d range = 0.57–0.88), except verbal retention (d = 0.04). A subset of the 2 groups that were matched on IQ and demographics similarly demonstrated poorer performance for the PTSD group on all neurocognitive domains (d range = 0.52–0.79), except verbal retention (d = 0.15). Within the PTSD group, executive functioning accounted for significant variance in verbal learning over and above IQ and processing speed (ΔR² = .06), as well as depression (ΔR² = .07) and PTSD severity (ΔR² = .06). This study demonstrated that female veterans with PTSD performed more poorly than females without PTSD on several neurocognitive domains, including verbal learning, processing speed, and executive functioning. Replication of these results using a control group of veterans with more similar trauma exposure, history of mild traumatic brain injury, and psychiatric comorbidities would solidify these findings.     

Compelled Attention: The Effects of Viewing Trauma-Related Stimuli on Concurrent Task Performance in Posttraumatic Stress Disorder

We examined the ability of Vietnam veterans with PTSD to focus attention on a primary digit detection task while concurrently viewing neutral or Vietnam-related picture and word distractors. Controlling for combat exposure, military service, and psychopathology, veterans with PTSD took longer to detect the target when Vietnam-related pictures were distractors. There were no reaction time differences when word stimuli were distractors. The latency effect was specific to trials with trauma-related pictures and did not spread to neutral trials interleaved within a mixed block of trauma and neutral pictures. Individuals with PTSD recalled proportionally more Vietnam-related words than other groups, implying differential attention to Vietnam-related words. Attending to trauma-related pictures interferes with performance of a concurrent task by individuals with PTSD.     

Description and Preliminary Outcomes of an In Vivo Exposure Group Treatment for Posttraumatic Stress Disorder

Prolonged exposure (PE) therapy is traditionally delivered individually to patients. To engage more veterans in care, an in vivo exposure group treatment was developed in an urban VA medical center. This treatment represented a modification of the in vivo exposure portion of PE, with the addition of in‐session, therapist‐assisted in vivo exposures. Here, we describe this 12‐week treatment and present preliminary outcome data. Demographics and pre‐ and posttreatment scores on the PTSD Checklist–Specific (PCL‐S) and Beck Depression Inventory–II (BDI‐II) were extracted from a program evaluation database. The sample included veterans with a diagnosis of posttraumatic stress disorder (PTSD) who participated in the in vivo exposure group between October 2010 and March 2014 and had available treatment outcome data (N = 43). The majority of participants in the sample were male (n = 41, 95.3%) and Black (n = 34, 79.1%). Participation in the in vivo group was associated with a significant decrease in PCL‐S scores, with a medium‐large effect size, t(42) = 5.35, p < .001, d = 0.73, and a significant decrease in BDI‐II scores, with a small effect size, t(38) = 2.55, p = .015, d = 0.23. Previous participation in an evidenced‐based treatment (EBT) was not associated with symptom change following the in vivo group. Findings suggest that in vivo exposure group therapy constitutes a promising intervention for individuals who decline EBTs or remain symptomatic after completing an EBT for PTSD. Further study of this treatment using a randomized controlled trial design is warranted.     

Comparison of Clinician‐ and Self‐Assessments of Posttraumatic Stress Symptoms in Older Versus Younger Veterans

Assessment of posttraumatic stress disorder (PTSD) in older adults has received limited investigation. The purpose of this study was to compare the severity of PTSD symptoms in treatment‐seeking older and younger U.S. veterans with PTSD. Participants were 360 male and 284 female veterans enrolled in 2 separate clinical trials of psychotherapy for PTSD. About 4% of the participants were age 60 years or older. Symptoms were assessed before treatment using clinician‐rated and self‐report measures. For men, only numbing symptoms were lower in older veterans; this was so in clinician ratings, d = 0.76, and self‐reports, d = 0.65. For women, clinician‐rated hyperarousal symptoms were lower in older veterans, d = 0.57. Clinician‐rated and self‐reported symptoms were strongly related, Bs = 0.95 and 0.80 in the male and female samples, respectively. Among men, clinician‐rated and self‐reported reexperiencing and hyperarousal symptoms were associated only in younger veterans. Accurate assessment of PTSD symptoms in older adults is essential to identifying and implementing effective treatment. Our findings suggest that some symptoms may be lower in older men, and that some symptoms of PTSD may be underdetected in older women. Future research should assess the combined effect of gender and age on PTSD symptom presentation.     

Prolonged Exposure and Sertraline Treatments for Posttraumatic Stress Disorder Also Improve Multiple Indicators of Social Functioning

Trauma survivors with posttraumatic stress disorder (PTSD) frequently also suffer from difficulties in social functioning that range across emotional, cognitive, and environmental domains. A detailed evaluation of the differential impacts of effective PTSD treatments on social functioning is needed. Men and women (N = 200) with chronic PTSD received 10 weeks of prolonged exposure (PE) or sertraline in a randomized clinical trial and were followed for 24 months. A secondary data analysis examined changes in social functioning with regard to fear of intimacy; receipt of social support; and distress, avoidance, and negative cognitions in social situations. Effects were examined between treatments over time, controlling for baseline functioning. There were large, durable improvements across all indices. Compared to sertraline, PE was more efficient at reducing fear of intimacy and distress from negative social cognitions by posttreatment, ds = 0.94–1.14. Patients who received sertraline continued to improve over the course of follow-up, ds = 0.54–1.17. The differential speed of therapeutic effects may argue for more direct mechanisms in cognitive behavioral interventions versus cascade effects in serotonin reuptake inhibitors. Notably, both treatments produced substantial social benefits for trauma survivors with social functioning difficulties, and effect sizes were comparable to typical reductions in PTSD, depression, and anxiety.     

Effects of Narrative Exposure Therapy on Posttraumatic Stress Disorder,Depression, and Insomnia in Traumatized North Korean Refugee Youth

Refugees affected by multiple traumatic stressors are at high risk for developing trauma-related mental disorders, including posttraumatic stress disorder (PTSD), depression, and insomnia, which is sometimes overlooked. The present study examined the effectiveness of narrative exposure therapy (NET) on trauma-related symptoms in a sample of North Korean refugee youth. We focused on sleep patterns in addition to changes in symptom severity for PTSD, depression, and internalizing and externalizing symptoms. North Korean refugee youth (N = 20) with PTSD were assigned to either an NET-based treatment group or a control group, which consisted of treatment as usual (TAU). There were clinically significant reductions in PTSD, depression, and internalizing and externalizing symptoms for the NET group, Hedges’ g = 3.6, but not the TAU group. The change in diagnostic status for PTSD was more notable for participants in the NET group compared to the TAU group. Of note, NET also produced a significant improvement in insomnia symptoms and sleep quality, Hedges’ g = 2.1. The substantial recovery regarding overall posttraumatic symptoms in the NET group was observed 2 weeks after the end of treatment and remained stable at 6-month follow-up. The results of the present study suggest that NET may be a treatment option for traumatized North Korean refugee youth and may also be effective for the treatment of sleep problems that arise from traumatic experiences.     

Technology‐Enhanced Stepped Collaborative Care Targeting Posttraumatic Stress Disorder and Comorbidity After Injury: A Randomized Controlled Trial

Posttraumatic stress disorder (PTSD) and its comorbidities are endemic among injured trauma survivors. Previous collaborative care trials targeting PTSD after injury have been effective, but they have required intensive clinical resources. The present pragmatic clinical trial randomized acutely injured trauma survivors who screened positive on an automated electronic medical record PTSD assessment to collaborative care intervention (n = 60) and usual care control (n = 61) conditions. The stepped measurement‐based intervention included care management, psychopharmacology, and psychotherapy elements. Embedded within the intervention were a series of information technology (IT) components. PTSD symptoms were assessed with the PTSD Checklist at baseline prerandomization and again, 1‐, 3‐, and 6‐months postinjury. IT utilization was also assessed. The technology‐assisted intervention required a median of 2.25 hours (interquartile range = 1.57 hours) per patient. The intervention was associated with modest symptom reductions, but beyond the margin of statistical significance in the unadjusted model: F(2, 204) = 2.95, p = .055. The covariate adjusted regression was significant: F(2, 204) = 3.06, p = .049. The PTSD intervention effect was greatest at the 3‐month (Cohen's effect size d = 0.35, F(1, 204) = 4.11, p = .044) and 6‐month (d = 0.38, F(1, 204) = 4.10, p = .044) time points. IT‐enhanced collaborative care was associated with modest PTSD symptom reductions and reduced delivery times; the intervention model could potentially facilitate efficient PTSD treatment after injury.     

Sensitivity and specificity of the PTSD checklist in detecting PTSD in female veterans in primary care

PTSD affects a substantial number of women in medical settings and is associated with significant distress and impairment. There are effective methods of treating trauma-related distress, but a minority seek such care. Thus, primary care is an important setting in which to identify individuals with PTSD. We sent questionnaires, including the PTSD Checklist—Civilian Version (PCL-C), to 419 female veterans who were seen in our primary care clinic in 1998; 56% (N = 221) returned the measures. A random subset (n = 49) was interviewed to establish psychiatric diagnoses. The results provide qualified support for the use of the PCL-C total score with a lowered cutoff score as a screening measure for PTSD in female veterans in primary care.     

The Evidence for Present‐Centered Therapy as a Treatment for Posttraumatic Stress Disorder

To examine the evidence for present‐centered therapy (PCT) as a treatment for posttraumatic stress disorder (PTSD), 5 randomized clinical trials that compared PCT to an existing evidence‐based treatment for PTSD were reviewed. A meta‐analysis was used to estimate between‐treatment differences on targeted measures, secondary measures, and dropout. PCT was found to be as efficacious as the comparison evidence‐based treatment in 3 of the 5 trials, and in the 2 cases where a no‐treatment condition was included, PCT was superior, with large effect sizes for targeted variables (d = 0.88, 0.74, and 1.27). When results were aggregated using meta‐analysis, effects for PCT versus an evidence‐based treatment for both targeted and secondary measures were small and nonsignificant (d = 0.13 and d = 0.09, respectively). As well, the dropout rate for PCT was significantly less than for the comparison evidence‐based treatments (14.3% and 31.3%, respectively). It appears that PCT is an efficacious and acceptable treatment for PTSD.     

Predictors for Excellent Versus Partial Response to Prolonged Exposure Therapy: Who Needs Additional Sessions?

In practice, the duration of psychotherapy is determined by the patient's response to treatment. Identifying predictors for treatment responses is of great clinical utility to guide clinicians in their treatment planning. Demographic characteristics, trauma history, comorbidity, and early reduction of posttraumatic stress disorder (PTSD) symptoms were examined as predictors of excellent versus partial response to prolonged exposure therapy (PE) for PTSD. Participants were 96 female assault survivors with chronic PTSD who received at least eight PE sessions with or without cognitive restructuring. Participants were classified as excellent responders (n = 27) or partial responders (n = 69) based on whether they achieved at least 70% improvement in self‐reported PTSD severity on the PTSD Symptom Scale–Self‐Report at the end of Session 8. Excellent responders terminated therapy after Session 9, and partial responders were offered up to three additional sessions. Logistic regression was conducted to investigate predictors of response to PE. Results showed that prior interpersonal violence and comorbid alcohol use disorder were associated with partial response. Comorbid depressive disorder and early PTSD symptom reduction were associated with excellent response. Being treated by a cognitive behavioral therapy expert predicted higher excellent response for patients with a history of prior interpersonal violence. The model accounted for 56.6% of the variance in treatment response and correctly predicted responder status for 83.3% of the sample. These findings contribute to the field's understanding of factors that predict or moderate response to PE and have implications for treatment planning.     

Change in Event Centrality and Posttraumatic Stress Disorder Symptoms During Intensive Treatment

Event centrality, defined as the extent to which a traumatic event becomes a core component of a person's identity (Berntsen & Rubin, 2006), is both a correlate and predictor of posttraumatic stress disorder (PTSD) symptoms, over and above event severity. These findings suggest that decreasing the perceived centrality of a traumatic event to one's identity might result in decreases in PTSD symptom severity. To date, few studies have examined how centrality is affected by PTSD treatment. The present study tested the hypotheses that change in centrality would be associated with both change in PTSD symptom severity and discharge PTSD symptom severity in an exposure‐based PTSD partial hospitalization program (N = 132; 86.0% White; 85.2% female; M age = 36 years). At discharge (i.e., after approximately 6 weeks of treatment), both PTSD symptoms and centrality had significantly decreased, ds = .70 and .98, respectively, with large effect sizes. Decreases in Centrality of Events Scale (CES) scores at posttreatment, baseline CES scores, and baseline PTSD Checklist for DSM‐5 (PCL‐5) scores were associated with change (i.e., decrease) in PCL‐5 scores, p < .001, as well as with posttreatment PCL‐5 scores, p < .001. Decreases in CES scores over time, baseline CES scores, and baseline PCL‐5 scores explained 31% of the variance in PCL‐5 change and 34% of the variance in posttreatment PCL‐5 scores. The results indicate the potential importance of decreasing the centrality of a traumatic event in PTSD treatment and recovery.     

Symptoms of Posttraumatic Stress Disorder are Associated with Exaggerated Neural Response to Surprising Errors

Posttraumatic stress disorder (PTSD) is characterized by exaggerated salience of previously innocuous cues and associated with hyperactivity of salience‐related brain regions. Recently, computational models have been deployed to operationalize salience more precisely regarding surprise‐driven learning, leading to findings that such learning is altered in anxiety‐related disorders. In the present study, a sample of 20 combat veterans completed a probabilistic learning task during fMRI scanning. We applied a computational model to generate a trial‐by‐trial surprise signal (i.e., unsigned prediction error or difference between the expected probability of an outcome and the actual observed outcome), which allowed us to examine the neural response to surprising events. We did not observe an association between PTSD symptoms and behavioral indices of learning in the task. Surprising errors were associated with increased activity in the left precuneus/inferior parietal lobule and right inferior parietal lobule, two parietal regions that are linked to salience processing. Additionally, PTSD symptom severity was positively associated with precuneus/inferior parietal lobule activation to surprising errors, r = .63, p = .004. Taken together, this pattern of results suggests that PTSD symptoms are specifically associated with an exaggerated response to surprising errors in salience‐related regions of the brain. This altered pattern of neural activity could represent a target for intervention to improve PTSD symptoms.